Guidelines - Community-Acquired Pneumonia in Children 3 months of age or older

DRUG ANTIBIOTICS

This optimal usage guide is mainly intended for primary care health professionnals. It is provided for information purposes only and should not replace the clinician’s judgement.

The recommendations were developed using a systematic approach and are supported by the scientific literature and the knowledge and experience of Quebec clinicians and experts.

For more details, go to inesss.qc.ca.

GENERAL INFORMATIONS

IMPORTANT CONSIDERATIONS

Viruses are the most frequently encountered pathogens in the first two years of life

(respiratory syncytial virus, influenza, human metapneumovirus, parainfluenza virus, adenovirus, coronavirus).

„ Risk factors of Streptococcus pneumoniae resistance : •

•

•

•

(the pathogens encountered from 0 to 3 months of age are provided for information purposes only) UNDER 1 MONTH OLD 1 TO 3 MONTHS OLD PRESCHOOL AGE SCHOOL AGE AND

ADOLESCENCE Respiratory viruses Respiratory viruses Respiratory viruses Streptococcus pneumoniae Group B streptococcus Streptococcus pneumoniae Streptococcus pneumoniae Mycoplasma pneumoniae Haemophilus influenzae

(non-typable) Chlamydia trachomatis Mycoplasma pneumoniae Chlamydophila pneumoniae Gram-negative bacteria Bordetella pertussis Chlamydophila pneumoniae Respiratory viruses

*Haemophilus influenzae type b has all but disappeared thanks to the vaccine. This infection occurs mainly in unvaccinated children.

PREVENTIVE MEASURES

„ Living in a smoke-free environment

„ Following the recommended vaccination schedule under the Québec Immunisation Program

„ Treating asthma appropriately

DIAGNOSIS

Pneumonia is diagnosed based on the following signs and symptoms :

• Fever • Cough

• Tachypnea • Desaturation

• Chest indrawing • Grunting

• Crepitant rales • Diminished breath sounds

Abdominal pain can also be a classic sign of pneumonia.

COMMUNITY-ACQUIRED PNEUMONIA IN CHILDREN 3 MONTHS OF AGE OR OLDER

MARCH 2016

COMMUNITY-ACQUIRED PNEUMONIA IN CHILDREN 3 MONTHS OF AGE OR OLDER Stay up to date at inesss.qc.ca

AGE-SPECIFIC CRITERIA FOR TACHYPNEA (taken from the Canadian Paediatric Society, 2015)

Age Approximate normal

respiratory rates (breaths/minute)

Upper limit that should be used to define tachypnea

(breaths/minute)

< 2 months 34 to 50 60

2 to 12 months 25 to 40 50

1 to 5 years 20 to 30 40

> 5 years 15 to 25 30

The symptoms of pneumonia may be non-specific, especially in infants and younger children.

Abrupt onset of rigors favours a bacterial cause.

Mycoplasma pneumoniae is typically characterized by malaise and headache for 7 to 10 days before the onset of fever and cough, which then predominate.

MEDICAL IMAGING

A chest x-ray is generally recommended to confirm the pneumonia diagnosis and avoid overdiagnosis. However, it is sparsely useful in children experiencing wheezing with typical presentation of bronchiolitis or asthma, because bacterial pneumonia is then very unlikely.

The Canadian Paediatric Society provides some information regarding medical imaging.

POTENTIAL INDICATIONS FOR HOSPITALIZATION :

• Age < 3 to 6 months

• Toxic or lethargic appearance • Severe respiratory distress • Oxygen requirement

• Underlying cardiac or pulmonary disease

• Immunodeficiency

• Complicated pneumonia (effusion, empyema, abscess, etc.) • Epidemiological context of a virulent/multidrug-resistant

pathogen

• Dehydration, inability to feed • Vomiting

• Failure to respond to oral antibiotics

• Low parental involvement to ensure treatment compliance

TREATMENT PRINCIPLES SUPPORTIVE TREATMENTS

„ It is important to reduce pain and fever by using an analgesic/antipyretic (acetaminophen or ibuprofen*), especially in the first few days.

„ It is important to maintain adequate hydration.

„ Antitussives are not recommended for children under 6 years of age.

*Ibuprofen is not recommended for children under 6 months of age.

HISTORY OF ALLERGIC REACTION TO A PENICILLIN ANTIBIOTIC

„

True penicillin allergy is uncommon. For 100 children with a history of penicillin allergy fewer than 6 will be

CONFIRMED

to have a true diagnosis of allergy and the reactions will be mostly delayed non-severe rashes.

•It is therefore important to carefully assess the allergy status of a patient who reports a history of allergic reaction to penicillin, before considering using alternatives to beta-lactams. For help, consult the decision- making tool in case of allergy to penicillins.

Stay up to date at inesss.qc.ca COMMUNITY-ACQUIRED PNEUMONIA IN CHILDREN 3 MONTHS OF AGE OR OLDER

FIRST-LINE TREATMENT OF COMMUNITY-ACQUIRED PNEUMONIA IN CHILDREN 3 MONTHS OF AGE OR OLDER

IF VIRAL PNEUMONIA PRESUMED

In children in good condition overall whose clinical presentation and imaging (if applicable) points to viral infection :

•

•

IF BACTERIAL PNEUMONIA PRESUMED¹

Antibiotic Daily dosage² Maximum dosage Treatment duration Amoxicillin 90 mg/kg/day PO ÷ TID 1 000 mg PO TID 7 to 10 day If antibiotics have

been used in the last 30 days orIf the child has not been vaccinated against Haemophilus influenzae type b

Amoxicillin- clavulanate³ (7:1 formulation)

Amoxicillin +or Amoxicillin- clavulanate³ (7:1 formulation)

90 mg/kg/day PO ÷ TID or

45 mg/kg/day PO ÷ TID 45 mg/kg/day PO ÷ TID+

1 000 mg PO TID or 500 mg PO TID 500 mg PO TID+

7 to 10 day

If history of allergic reaction to a penicillin antibiotic

Click here to view the community-acquired pneumonia in children algorithm for help in choosing an antibiotic therapy

IF ATYPICAL PNEUMONIA PRESUMED⁴

Antibiotic Daily dosage Maximum dosage Treatment duration

Clarithromycin 15 mg/kg/day PO ÷ BID 500 mg PO BID 7 to 10 days

Azithromycin 10 mg/kg PO daily on day 1, then 5 mg/kg PO daily

x 4 days

500 mg PO daily, on day 1, then 250 mg PO daily

x 4 days 5 days

1. For school-aged children in whom it is not possible to eliminate atypical pneumonia, a macrolide (clarithromycin or azithromycin) can be added to first-line antibiotic treatment.

2. Although the Canadian Paediatric Society and several clinicians prefer TID administration, BID administration remains an alternative if there is a suspected risk of non-compliance with treatment.

3. The 7:1 formulation (BID) of amoxicillin-clavulanate is preferred due to its higher digestive tolerance. The 200 mg/5 ml and 400 mg/5 ml formulations and 875 mg tablets contain the correct ratio of amoxicillin and clavulanic acid. Some clinicians use a combination of amoxicillin (45 mg/kg/day) and amoxicillin-clavulanate (7:1 formulation) (45 mg/kg/day) to reduce adverse effects (total of 90 mg/kg/day, 14:1 equivalent); volumes of amoxicillin and amoxicillin-clavulanate to be given could be different.

4. Subacute onset, cough-dominant, minimal leukocytosis and non-lobar infiltrates, generally in school-aged children.

If the patient has a fever that persists for more than 48 to 72 hours after the start of treatment or if there is clinical deterioration: reassess the patient and repeat the x-ray to look for complications that would require hospitalization.

MAIN REFERENCES

Bradley JS, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C, et al. “Executive summary: the management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America.” Clin Infect Dis 2011;53(7):e25–76.

Harris M, Clark J, Coote N, Fletcher P, Harnden A, McKean M, Thomson A. “British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011.” Thorax 2011;66(Suppl 2):ii1–23.

Le Saux N and Robinson JL. “La pneumonie non compliquée chez les enfants et les adolescents canadiens en santé: points de pratique sur la prise en charge.” Paediatr Child Health 2015;20(8):446–50.

Please note that other references have been consulted.

Stay up to date at inesss.qc.ca COMMUNITY-ACQUIRED PNEUMONIA IN CHILDREN 3 MONTHS OF AGE OR OLDER

Any reproduction of this document in whole or in part for non-commercial use is permitted on condition that the source is mentioned.

COMMUNITY-ACQUIRED PNEUMONIA IN CHILDREN

A S S ES S T H E S EV ER IT Y O F T H E I N IT IA L R EA C TI O N D EC IS IO N –M A K IN G F O R C H O O S IN G A B ET A -L A C TA M A N D T H E C O N D IT IO N S O F A D M IN IS TR AT IO N

Vague history

THE FOLLOWING CAN BE PRESCRIBED SAFELY

DISSIMILAR cephalosporins Cefuroxime axetil⁶ SIMILAR cephalosporins

Cefprozil⁷ if history of allergy does not suggest an immediate reaction…

If in doubt about the possibility of an immediate reaction...

a 1-hour observation period after the administration of the 1^st dose of Cefprozil⁷ under the supervision of a health professional could be advised according to the clinician judgment.

IF A BETA-LACTAM⁸ CANNOT BE ADMINISTERED, THE FOLLOWING CAN BE PRESCRIBED...

Clarithromycin OR Azithromycin Unconvincing

history reported by patient

or family

Non-severe reaction Immediate reaction¹ Isolated cutaneous

involvement (urticaria and/or angioedema)

Immediate reaction Anaphylaxis⁴

Penicillin allergy

CONFIRMED⁵ (severe or non-severe

reaction only)

Delayed reaction Hemolytic anemia Renal involvement Hepatic involvement DRESS, SJS/TEN, AGEP Delayed reaction^2,3

Isolated cutaneous involvement (Rash and/or urticaria

and/or angioedema)

Delayed reaction Severe skin reaction (desquamation, pustules, vesicles, purpura with fever or joint pain, but no DRESS,

SJS/TEN, or AGEP) Serum sickness³

Immediate reaction Anaphylactic shock (with or without intubation) Severe reaction

PRESCRIBE THE FOLLOWING WITH CAUTION

DISSIMILAR cephalosporins Cefuroxime axetil⁶

SIMILAR cephalosporins

Cefprozil⁷ONLY if serum sickness-like reactions occurred in childhood³. The 1^st dose should always be administered under medical supervision.

If history of :

•Immediate reactions, a drug provocation test should be performed;

•Delayed reactions, the patient or his/her family should be informed of the possible risk of recurrence in the days following initiation of the antibiotic.

PRESCRIBE THE FOLLOWING WITH CAUTION

Penicillins

Amoxicillin +/- Clavulanate

The 1^st dose should always be administered under medical supervision.

If history of :

•Immediate reactions, a drug provocation test should be performed;

•Delayed reactions, the patient or his/her family should be informed of the possible risk of recurrence in the days following initiation of the antibiotic.

Very severe reaction

AVOID PRESCRIBING Beta-lactams⁸

Choose another class of antibiotics.

AVOID PRESCRIBING

Penicillins

Amoxicillin +/- Clavulanate SIMILAR cephalosporins

Cefprozil⁷ for all other clinical situations (with the exception of children with a history of serum sickness-like reactions³, as described above).

SEVERITY OF PREVIOUS ALLERGIC REACTION TO PENICILLIN ANTIBIOTICS

or

! or

or or or

or

1. Immediate reaction (type I or IgE-mediated): usually occurs within one hour after taking the first dose of an antibiotic.

2. Delayed reaction (types II, III and IV): may occur at any time from one hour after administration of a drug.

3. Delayed skin reactions and serum sickness-like reactions that occur in children on antibiotic therapy are generally non- allergic and may be of viral origin.

4. Anaphylaxis without shock or intubation: requires an extra level of vigilance.

5. With no recommendations concerning other beta-lactams.

6. Cefuroxime axetil as an oral suspension is not widely used due to its unpleasant taste. See the product monograph to learn how to improve the taste of this medication.

7. Cefprozil has not been approved by Health Canada for the treatment of pneumonia. However, it is frequently prescribed for this purpose, and experts agree that this antibiotic is an acceptable treatment option for pneumonia.

8. Penicillins, cephalosporins and carbapenems.

PRESCRIBE THE FOLLOWING Clarithromycin OR Azithromycin

For dosages see next page

and

and

For further information, see

the interactive tool and the decision-making tool.

AGEP : acute generalized exanthematous pustulosis;

DRESS : drug reaction with eosinophilia and systemic symptoms;

SJS : Stevens–Johnson syndrome;

TEN : toxic epidermal necrolysis.

FIRST-LINE ANTIBIOTIC THERAPY FOR BACTERIAL PNEUMONIA PRESUMED

IF HISTORY OF ALLERGIC REACTION TO A PENICILLIN ANTIBIOTIC

Antibiotic Daily dosage² Maximum dosage Treatment duration

Beta-lactams

recommended, according to the clinical judgement support algorithm

Cefuroxime axetil³

30 mg/kg/day PO ÷ BID 500 mg PO BID

7 to 10 days Cefprozil⁴

Amoxicillin 90 mg/kg/day PO ÷ TID 1 000 mg PO BID

Amoxicillin/Clavulanate⁵ (7:1 formulation)

OR Amoxicillin + Amoxicillin-Clavulanate⁵

(7:1 formulation)

90 mg/kg/day PO ÷ TID OR

45 mg/kg/day PO ÷ TID 45 mg/kg/day PO ÷ TID+

1 000 mg PO TID OR 500 mg PO TID 500 mg PO TID+

Alternative if a beta-lactam

cannot be administered

Clarithromycin 15 mg/kg/day PO ÷ BID 500 mg PO BID 7 to 10 days

Azithromycin 10 mg/kg PO daily, on day 1, then 5 mg/kg PO daily

x 4 days

500 mg PO, daily, on day 1, then 250 mg PO daily

x 4 days 5 days

1. For school-aged children in whom it is not possible to eliminate atypical pneumonia, a macrolide (clarithromycin or azithromycin) can be added to first-line antibiotic treatment.

2. Although the Canadian Paediatric Society and several clinicians prefer TID administration, BID administration remains an alternative if there is a suspected risk of non-compliance with treatment.

3. Cefuroxime axetil as an oral suspension is not widely used due to its unpleasant taste. See the product monograph to learn how to improve the taste of this medication.

4. Cefprozil has not been approved by Health Canada for the treatment of pneumonia. However, it is frequently prescribed for this purpose, and experts agree that this antibiotic is an acceptable treatment option for pneumonia.

5. The 7:1 formulation (BID) of amoxicillin-clavulanate is preferred due to its higher digestive tolerance. The 200 mg/5 ml and 400 mg/5 ml formulations and 875 mg tablets contain the correct ratio of amoxicillin and clavulanic acid. Some clinicians use a combination of amoxicillin (45 mg/kg/day) and amoxicillin-clavulanate (7:1 formulation) (45 mg/kg/day) to reduce adverse effects (total of 90 mg/kg/day, 14:1 equivalent); volumes of amoxicillin and amoxicillin-clavulanate to be given could be different.

6. Penicillins, cephalosporins and carbapenems.

If the cautious administration of penicillin is the option chosen, opt for amoxicillin/clavulanate instead of amoxicillin alone if the following applies: antibiotics used in the past 30 days.

!

!

COMMUNITY-ACQUIRED PNEUMONIA IN CHILDREN